Case series and techniques of Descemet’s Stripping Automated Endothelial Keratoplasty for severe bullous keratopathy after birth injury

Abstract

BackgroundTo evaluate clinical outcomes of Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK) for severe bullous keratopathy that develop as a late complication of endothelial injury to the baby during forceps delivery at birth.Case presentationsFour eyes (four patients; mean age, 51.5 years) with severe bullous keratopathy as a late complication of forceps delivery at birth were enrolled. All patients had amblyopia from childhood due to cloudy cornea. Nontheless, DSAEK was indicated in these patients for the irritation and severe light sensation caused by apparent bullous change of the injured cornea. All patients underwent DSAEK and two patients had simultaneous cataract surgery. Intraoperative and postoperative complications were recorded. Postoperative donor endothelial-cell densities (ECDs) were measured prospectively at six and 12 months and compared with preoperative values. Best corrected visual acuity (BCVA) was measured at 6 and 12 months postoperatively. All cases required corneal epithelial removal; two cases with simultaneous cataract surgeries required lens anterior capsule staining by trypan blue and illumination of the cornea for visualization. There were no cases of graft dislocation or primary graft failure. Mean BCVA improved from 0.06 to 0.15 at 6 months and to 0.38 at 12 months. Postoperative ECD was 2270 cells/mm2 (mean loss, 24.4 %) at 6 months and 2130 (mean loss, 29.1 %) at 12 months. Postoperative intraocular pressure elevation was observed in two cases, and a rejection episode occurred in one case at 4 months postoperatively.ConclusionsIn this case series, the clinical outcome of DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance, which was comparable to uncomplicated cases. Cataract and DSAEK surgery was safely performed using techniques including epithelial removal, lens anterior capsule staining and illuminating the cornea, which enabled better visualization of the anterior chamber.

Results of Descemet Stripping Automated Endothelial Keratoplasty for the Treatment of Late Corneal Decompensation Secondary to Obstetrical Forceps Trauma

“…4,9 Corneal edema occurs at a late stage in the adulthood of these patients and probably plays no role in the development and degree of amblyopia; moreover, in some cases forceps lesions may spare the central optical zone but cause more paracentral or peripheral stromal edema (Fig. 1).…”

Obstetrical forceps-induced Descemet membrane tears

“…Most of the authors have reported a normal IOP in children with FIDMTs. Various authors such as Ponchel,[ 14 ] Kobayashi,[ 20 ] Kancherla,[ 21 ] and Hayashi[ 22 ] reported raised IOP after surgical interventions such as Descemet’s puncture with air injection, Descemet stripping automated endothelial keratoplasty (DSAEK), and penetrating keratoplasty (PKP). The presumed mechanism could be localized iridocorneal adhesions, pupillary block glaucoma, inflammation, or steroid use.…”

“…These associated injuries can indirectly aid clinicians in diagnosing missed FIDMTs. Few of the injuries, as reported by McDonald[ 6 ], Kobayashi,[ 20 ] and Simpson,[ 23 ] include…”

“…[ 13 ] It was first performed by Ponchel[ 14 ], and the youngest reported case of DSAEK in this setting is that of an eight-year-old child. [ 20 ] It was previously presumed that DSAEK requires a completely smooth host corneal rear surface for donor attachment and irregular endothelial surface induced by FIDMTs could prevent its successful attachment. [ 27 ] However, with various authors recently reporting successful outcomes of DSAEK in similar eyes without notable complications, the trend appears to be changing [ Fig.…”

“…The indications, preoperative assessment, and surgical steps of DSAEK are compiled in Table 3 . [ 14 20 ] Although the efficacy of DSAEK in clearing the affected cornea remains undisputed, sometimes, graft dislocation—either resolving with rebubbling or leading to primary donor failures—can also be encountered. [ 13 14 20 25 33 ] Presently, the effect of DSAEK grafts on astigmatism in FIDMTs remains unclear.…”